Failure to Prevent Unauthorized Smoking and Secure Smoking Materials
Penalty
Summary
The facility failed to ensure that a resident only smoked in designated, safe areas and that tobacco and smoking supplies were kept in secure locations, as required by facility policy. The resident, who was cognitively intact and independently ambulatory, had a history of type 2 diabetes mellitus, cerebral infarction, and nicotine dependence. Despite being assessed as a potentially unsafe smoker and having a care plan indicating non-compliance with smoking protocols, the resident repeatedly smoked in his room and other non-designated areas. Multiple staff members, including the administrator, DON, nurse manager, CNAs, and RNs, reported finding ashes, smelling smoke, and observing the resident with cigarettes and lighters in his room and hallways. Progress notes documented several instances where the resident's room and bathroom smelled of smoke, ashes were found, and the resident was caught with smoking materials. The facility's smoking policy required that smoking materials be secured at the nurses' station and prohibited smoking in resident rooms, allowing it only in designated outdoor areas. Despite repeated education and reminders from staff, the resident continued to access and use tobacco products in unauthorized areas, sometimes obtaining cigarettes and lighters from outside the facility or visitors. The facility was aware of the ongoing issue, as documented in interviews and progress notes, but the non-compliance persisted, resulting in a failure to maintain a safe environment free from accident hazards related to smoking.